Introduction and Hypothesis <p>Although the role of uterine preservation during open sacrocolpopexy was well-explored, data regarding laparoscopic sacrocolpopexy (LSC) are controversial. This study was aimed at comparing the risk of mesh exposure between LSC with total hysterectomy and the uterine-preserving approach.</p> Methods <p>This retrospective cohort study included 198 patients who underwent LSC for pelvic organ prolapse. Based on surgical approach, patients were divided into two groups: those with concomitant total hysterectomy (<i>n</i> = 169) and those who underwent uterus-preserving LSC (<i>n</i> = 29). The primary outcome was mesh exposure. A logistic regression model was employed to calculate odd ratios (OR) and 95% confidence interval (CI) while adjusting potential confounding factors. Secondary outcomes included the composite success, anatomical outcomes, and self-reported symptom improvement.</p> Results <p>The median follow-up time of the whole cohort was 32 months. The incidence of mesh exposure was higher in the hysterectomy group compared with the uterine preservation group (27 out of 169, 16.0% vs 1 out of 29, 3.4%, <i>p</i> = 0.13). After controlling confounding factors, concomitant hysterectomy was associated with a nearly tenfold increased risk of mesh exposure (adjusted OR, 9.9; 95% CI, 1.5 to 199.0). There was no statistically significant difference in the composite success endpoint between the two groups (107 out of 131, 81.7% vs 21 out of 25, 84.0%, <i>p</i> = 0.99).</p> Conclusions <p>Concomitant hysterectomy during LSC was associated with increased risk of mesh exposure, and the composite success rates of the two groups were similar.</p>